Tuesday, February 26, 2008

Antibiotics overused in Alzheimer patients

Should people with Alzheimer's disease/dementia be treated with antibiotics? According to a new study, they say that antibiotics are being overused in patients with dementia and antibiotic use should be considered more carefully especially in this time of antibiotic resistant superbugs. (AP)

The study raises ethical questions about when it's acceptable to withhold perhaps futile treatment and let people die, and whether public health issues should ever be considered.

"Advanced dementia is a terminal illness," said study co-author Dr. Susan Mitchell, a senior scientist with the Harvard-affiliated Hebrew Senior Life Institute for Aging Research in Boston. "If we substituted 'end-stage cancer' for 'advanced dementia,' I don't think people would have any problem understanding this."

People wouldn't have a problem understanding this? Of course, when you paint a picture like that. Here's the question, though- What is advanced dementia? There really is no consensus definition. Of course, really end stage cases even medical students can diagnose. But, the problem is that there is a spectrum of diagnosis. Where do you draw the line between moderate dementia and advanced dementia? There is no agreement with this.

I can see both sides of the end of life debate getting ready to do battle again. Remember Terri Schiavo? Remember Baby Emilio? Remember the use of chip implants in Alzheimer patients? The use of antibiotics in dementia/alzheimer patients is just another chapter in this debate.

One side is saying that the progression of antibiotic resistant organisms can be stopped by appropriately prescribing antibiotics - meaning not those patients with advanced Alzheimer's disease. The other side is saying once you limit antibiotic treatment for people with Alzheimer's, the danger is there to start using the same argument to stop treatment of other medical conditions (like high blood pressure). What's your take on this debate? I'm curious....

9 comments:

Funny, this is a topic that has just been discussed at the International House of Pragma. We're working on a post on it at the moment.

I have a great-aunt in this position - moderate to severe AD (recognizes some family members but not all, minimal participation in self-care activities, life pretty much limited to the walls of the SNF, the hospital and the doctor's office), multiple serious comorbidities (unstable CHF, type II diabetes, emphysema). She's no longer well or coherent enough to attend family events, participate in group outings or really recognize one day as different from the one before.

She also suffers from a more severe condition - loved ones with unrealistic expectations and blurred perceptions of her reality.

The combo is lethal, and leads to Medical Stupidity. She's Medicaid/Medicare dual-eligible, and she's taking a truly impressive array of brand-name medications, including Plavix and Lipitor, Spiriva and Actos, Zyprexa and Exelon (to name but a few).

The Zyprexa may kill her (it's certainly not helping her glucose control), but it improves behavior. Same with the Exelon. There's good evidence for cholinesterase inhibitors up to the end.

But what, exactly, is the point of aggressive glucose control or atherosclerosis treatment in someone in her shape? It's certainly not to protect her high-functioning mind from a body that is betraying her. . .

Oh, yeah. CYA for the doctors and comfort for her family that they're doing "everything they can".

Less is more. When she gets a florid pneumonia, I *hope* they withhold antibiotic treatment and palliate the fever and presumed discomfort as aggressively as possible.

But they won't.

They'll keep her alive to let it all happen again. They mistake recognizing her sister after 15 minutes as still having "quality of life". They think there's some better, peaceful end than a bad respiratory infection, just waiting for her. They think it's God's Will that she get every possible intervention known to man, paid for by the taxpayers, because if she didn't get it, it's morally tantamount to murder.

I can't help but wonder the SNF's role in all this. Keeping the profoundly unwell alive longer, with a return to the SNF, preserves their revenue stream.

I would like to see SNF nurse leadership sit down with the families and say, "We can't run the risk of a resistant bug harming the other people here - your loved one isn't going to functionally improve after this treatment, and it's likely to contribute to the death of someone else's loved one."

Maybe there's an easy-to-use guideline. . . measure the radius that the patient moves in on a daily basis to determine quality of life. Bed only? Bed and beside commode? Bed and bathroom? Entire apartment? Entire home? Community at large? Local travel? Long distance travel? Somewhere on that continuum is an indication that someone is highly likely not to be experiencing meaningful quality of life, and the use of life-sustaining interventions isn't helping them, and presumably is harming those around them. If you're bedridden and have been for months, what's the goal of the antibiotic therapy? Palliation of symptoms? Time to discuss other options.

I guess if someone has severe enough pneumonia, then we could also say, without antibiotics, they may also have end stage illness, so maybe we should just with hold antibiotics based on that assumption? Doesn't that sound silly?

Here is what I feel about all this. When my mom had progressed to last stage of alz., if she became ill and required an antibiotic to get better, and I refused to take her for medical treatment based on the fact she had ALZ., I hope there would be someone who would turn me in for elderly abuse. Because that is what it is.

Please note; I generally don't engage in vicious character assassinations online - it's not my style. There's just something in Cathy's comment that makes me incredibly upset, and I open up with both barrels, because this is something I'm very passionate about, and Cathy uses a classic piece of fallacious reasoning to compare withholding antibiotic therapy to inducing pain, a view supported neither by the science or by simple reasoning. If you're the gentle sort who doesn't like to see this sort of thing, skip over. This is not one of my nicer writings.)

Cathy:

It's simple. I am no longer human when I don't recognize my self or my loved ones, when I can't participate in my own life in a meaningful way. Existing in a reality where I cannot interact with those I love is the very definition of Hell. Advanced dementia is an eternal separation from that which you know and value.

I'm going to be uncharacteristically petty and assume from your vaguely superior tone that you think less of people who have family members in out of home care; I know there are things I can't do well, one of them being a full-time caregiver for a demented person. Destroying my family life and my career to care for an elder who enjoys being around peers and having more opportunities for activity, socialization and a reasonable routine is not a good use of my resources, especially when the evidence shows that family caregivers are subject to more morbidity and mortality when they assume responsibilities for in-home care. My great-aunt isn't my only LO who is going to die with a degenerative brain condition - I'm dealing with this on a daily basis with a parental figure. At the end of this, they are going to die, and martyring myself for their cause when I've still got 30 years or more of a career, volunteerism and philanthropy ahead of me to benefit others is selfish and stupid.

Here's the ugly reality; people with pneumonia suffer whether you give them antibiotics or not. Here's a citation:

Nobody is proposing not treating their symptoms - pain, fever, etc. What they're proposing is reducing the emergence of antibiotic-resistant superbugs that could kill people who have some remaining quality of life left. It's ridiculous to assume that palliative care wouldn't be part of these individual's care plans, and implying it wouldn't be reflects your bias against "good death" versus "keeping a heart beating at any cost", which is the truest, most common form of elder abuse known.

If my LO got pneumonia right now? I'd treat it aggressively, despite him having pretty advanced dementia and not having disease-modifying treatments on the horizon for his form. If he was bedridden? No way in heck. He'd have excellent fever and pain control, oxygen, pulmonary toilet, positioning and everything else, with the overriding goal of his comfort.

I'm just not nearly selfish enough to feel compelled to "cure" the infection just so he can live longer seeing nothing of the world than his bed, experiencing no joy. I sleep with a clear conscience knowing that I don't believe in torturing old people who can't decide for themselves with futile medical "care".

Ok, I'm going to step in here. I knew when I wrote this post that I would strike a nerve. First of all, I appreciate people passionately expressing their opinion on this issue.

Fortunately, or unfortunately, I see and experience both sides of this issue everyday in my job. Dealing with MRSA and other resistant organisms in my office and at the hospital is a real problem - a problem that is only going to get worse.

I have more of a fight with parents of young children trying to convince them that a cold is just a cold - and doesn't need antibiotics - I have more of a problem with them then talking to children of elderly parents.

With that in mind, the thought of withholding treatment for "advanced dementia," I'm still mulling over that. What does "poor quality of life" mean, anyway? Who am I to judge what a person's quality of life is? Sure in extreme cases, it's pretty well clear cut.

But, here's the reason I wrote this post. What about the people I see everyday who are just losing their memory - some in their 30s, 40s, and 50s. I know that eventually they will have advanced dementia - that is if their high blood pressure or heart disease doesn't get them first.

If I know they will eventually end up with advanced dementia, and I don't want them to suffer with that, why not stop their blood pressure medicine or cholesterol medicine now to prevent that eventual "poor quality of life"?

Now, I would never do that, but not treating advanced dementia patients with antibiotics is the beginning of a slippery slope, and until I think about it more, it just doesn't sit right with me at this point. That's my take....

It has been interesting following this discussion. I find "character assassination" to be in bad taste personally even the use of those words get my goat up. We are all different and we are all entitled to an opinion. I believe my Mother succumbed in the end to hospital infection and I never did find out if they with held antibiotic. My suspicions are of course that they did. She did not have Alz and only had mild dementia. Why do I believe this? The same night she was admitted they had this little "end of life" chat with me before there was even a good diagnosis. This is wrong but maybe in our overstretched public health care system some beurocrat determines and age cut off for life and death. Treat all persons the same, give them whatever will make their live comfortable, we are not God to determine who shall and shall not receive medicine. Feeding tubes and breathing tubes are a totally different issue as in the Shiavo case...ciao

My mother's living will states no antibiotics if she is in a terminal state. The nursing home decided that although she is completely dependent on others, can only eat a pureed diet, and doesn't know anyone, she is happy so she has a good quality of life. They felt that dementia is not a terminal decease and they gave her antibiotics. I understand some people believe that you should prolong a life at all costs, however this was not what mom wanted and anyone who expresses those wishes when they have a sound mind should have those wishes honored.